G (Discontinuation of Ventilatory Support), Re

In deciding whether life-sustaining treatment should continue, the court must focus on the patient’s continuing best interests. The question is whether the treatment provides overall benefit, assessed by weighing its benefits against the burdens of the treatment and the underlying condition. Treatment may be futile where it cannot improve the underlying condition and the patient lacks any meaningful ability to derive benefit from continued life. The fact that death is not immediately imminent does not prevent treatment limitation where prolongation confers no overall benefit. Parental wishes command respect but cannot displace the child’s best interests. Protracted disagreement, mediation or the need for further opinions cannot justify avoidable delay where the child’s welfare and dignity are at stake.

Manchester University NHS Foundation Trust sought a declaration that continued long-term ventilatory support for G, a seven-and-a-half-year-old child with profound brain damage and a prolonged disorder of consciousness, was no longer in her best interests. G had spent approximately six years in paediatric intensive care. The medical evidence established severe, irreversible neurological impairment, unpredictable respiratory failure, no prospect of recovery and substantial burdens from ongoing treatment. The parents opposed withdrawal, relying on their faith, hope and perceptions of G’s responsiveness. A treating expert supported continued ventilation in a less intensive setting, while the Guardian ultimately supported withdrawal. The central issue was whether continued ventilation provided G with sufficient benefit to outweigh its burdens.

1. Declaration granted. Continued ventilatory support was no longer in G’s best interests and was contrary to them. The treatment served only to prolong life, without prospect of improving her underlying condition or enabling her to derive meaningful benefit from continued life.
2. The governing approach was that identified in Aintree University Hospitals Foundation Trust v James [2013] UKSC 67; [2013] 3 WLR 1299. The court must ask whether the contemplated treatment is, and continues to be, in the patient’s best interests. The issue is not framed as whether treatment should be withheld. Futility requires consideration of whether treatment is ineffective or provides no benefit.
3. The court accepted that the RCPCH guidance was permissive rather than prescriptive. Treatment limitation could be considered where death was inevitable but not immediately imminent, where treatment burdens outweighed benefits, where the burdens of the underlying condition were themselves overwhelming, or where the child lacked the ability to benefit.
4. The evidence established that G had a profound and irreversible disorder of consciousness, unpredictable respiratory drive, progressive physical deterioration and substantial burdens from ventilation and associated care. Lay observations and educational materials could not displace the medical evidence without an appropriate clinical basis. The parents’ views were important, but their hope and religious convictions could not eclipse G’s own best interests.
5. The delay was unacceptable. Mediation may be useful, but its objective must be to determine the child’s best interests, not to compromise between parental wishes and clinical opinion. A second opinion and any subsequent mediation must proceed within the child’s timescales. A child’s severe brain damage or limited awareness provides no justification for delay and may aggravate the failure to protect the child’s welfare and dignity.